An Iranian Consensus Document for Nutrition in Critically Ill Patients, Recommendations and Initial Steps toward Regional Guidelines.

Seyed Mohammadreza Hashemian, Robert G. Martindale , Hamidreza Jamaati , Ali Amirsavadkouhi , Salahaddin Mahmudi Azer , Mahdi Shadnoush , Seyed Hossein Ardehali , Atabak Najafi , Arezoo Ahmadi , Seyyed Reza Seyyedi , Ata Mahmoodpoor , Omid Moradi , Saeed Abbasi , Saeed Hosseini , Reza Shahrami , Saeed Abdi , Zahra Sepehri , Babak Omranirad , Seyed Amir Mohajerani , Pejman Rohani , Aliakbar Sayyari , Hossein Imani , and Ali Akbar Velayati 1 1 Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran, 2 Oregon Health and Science University, Portland, OR, 3 Chronic Respiratory Diseases Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran, 4 Urmia University of Medical Sciences, Urmia, Iran, 5 Department of Clinical Nutrition, Faculty of Nutrition and Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran, 6 Department of Critical Care, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran, 7 Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran, 8 Lung Transplantation Research Center, Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran, 9 Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran, 10 Department of Anesthesiology and Critical Care, Iran University of Medical Sciences, Rassol-e-Akram Complex Hospital, Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran, 11 Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran, 12 School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran, 13 Anesthesiologist, Intensivist, 14 Department of Gastroenterology, Shahid Beheshti University of Medical Sciences, Tehran, Iran, 15 Department of Internal Medicine, Zabol University of Medical Sciences, Zabol, Iran, 16 Department of Pediatric Gastroenterology, Hepathology and Nutrition, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.


INTRODUCTION
Short-term and prolonged metabolic stress seems to have major impact on critically ill patients. Indeed; the metabolic stress is known to increase both morbidity as well as mortality in Intensive Care Unit (ICU) patients.
Nutritional support can deliver energy and metabolic demands of critically ill patients in ICU (1). Nutrition support refers to enteral or parenteral provision of calories, protein, electrolytes, antioxidants, vitamins, minerals, trace elements, and fluids which may optimize recovery from critical illness(2). This support is aimed to meet energy demands and to avoid protein-energy deficit and consequent negative nitrogen balance(3). Indeed, malnutrition in critically ill patients is known to underline a number of potential complications including; hypercatabolism, impaired ventilatory drive, prolonged length of mechanical ventilation, increased septic complications, increased length of stay and even mortality rate (4)(5)(6).
The changes in metabolic pathways due to metabolic stress in critically ill patient result in a highly complex and dynamic metabolic state. This in turn leads to difficult, if not impossible, safe and effective management of nutrient in critically ill patient. In addition, the degree of existing malnutrition, the severity of illness, time of the initiation of nutritional support and adequacy of nutritional support, are known to affect outcomes in critical illness (7,8). However; a systematic review has shown that there TANAFFOS are no specific and identical statistics on the effects of nutrition support on patients' outcomes in intensive care unit, to this end nutritional support for critically ill patient in ICU remains a challenge for intensive care physicians (9).
Previous data shows that patient's poor nutritional status is associated with increased length of hospital stay, as well as increased morbidity, mortality and medical expenses. It is also assumed that malnutrition is a prognostic factor for patients' survival in critical illness. Malnutrition rate in general population has been estimated at 20-50% in the world with validation of similar statistics in Iranian studies (10,11). It is likely that the rate of malnutrition is higher in hospitalized patients. Indeed, malnutrition is estimated at 40-45% among patients with gastro-enteric diseases (12,13). Interestingly, a different Iranian Study has estimated the malnutrition at about only 11% among hospitalized patients (11). Perhaps, dissimilar patient populations, patient socioeconomic status, and variable definitions of malnutrition in may underline this wide range of difference in above mentioned studies. Thus; further studies and more regionally agreed upon, definition for malnutrition is needed to overcome the above mentioned discrepancy (14). It is likely that insufficient information among health care providers, regarding sufficient nutritional support, contributes to high rate of malnutrition among patients in Iranian health care facilities. Thus, providing regional guidelines may help to improve patients' nutritional status and hence their general conditions and overall outcomes in Iranian Hospitals (11

Measuring Energy Expenditure
Indirect calorimetry involves measuring oxygen consumption (VO2) and carbon dioxide production (VCO2) (   Table 4. 3. A summary of essential nutrients is provided in table 5. 6. Overfeeding patients with critical illnesses has many consequences depicted in Table 6. 9. Another parameter derived from indirect calorimetry is respiratory quotient. If this ratio is less than 0.85 it is a sign of poor nutrition, and if the ratio is more than one it is a sign of over nutrition (44,45). In Iran, the medical ethics is based on both medical aspects and Islamic laws. From the perspective of Islam, nutritional support is considered as a basic an ethical care, not as a medical treatment. In Islamic law and tradition, the withholding or withdrawing of nutrition or hydration resulting in starvation, is seen as a greater harm than any potential complications of that treatment. To this end it is advised that starvation has to be avoided in such situations (42,48).